Publications by authors named "Virinder Kumar Bansal"

51 Publications

Early Versus Delayed Cholecystectomy for Acute Biliary Pancreatitis: A Systematic Review and Meta-Analysis.

World J Surg 2022 Jun 19;46(6):1359-1375. Epub 2022 Mar 19.

Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India.

Background: Recommendations regarding the timing of cholecystectomy for acute biliary pancreatitis (ABP) require a systematic summary of current evidence to guide clinical practice. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing early cholecystectomy (EC) versus delayed cholecystectomy (DC) in patients with ABP.

Methods: We searched databases Medline, Embase, SCOPUS, Web of Science and Cochrane CENTRAL for randomized controlled trials addressing this question. Pairs of reviewers abstracted data and assessed the risk of bias in included studies. A random-effects meta-analysis was done to study the effect of the timing of cholecystectomy on outcomes of interest in patients with ABP. GRADE methodology was used to rate the quality in the body of evidence for each outcome as high, moderate, low, or very low.

Results: 11 randomized trials (1176 participants) were included. High-quality evidence from seven RCTs (867 participants) showed a statistically significant reduction in the risk for recurrent biliary events in favour of early cholecystectomy (RR 0.10, 95% CI 0.05 to 0.19, I = 0%). High-quality evidence from five trials was in favour of early cholecystectomy with a significant reduction in the risk 7of recurrent pancreatitis (RAP) in comparison to delayed cholecystectomy (RR 0.21, 95% CI 0.09 to 0.51, I = 0%).

Conclusion: This review showed that EC has definite advantages over DC in terms of reducing recurrent pancreaticobiliary events and LOS following mild ABP. However, more RCTs are required to study the role of EC in patients with moderately-severe and severe ABP. Trial Registration Protocol registered on Prospero (CRD42020192823).
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http://dx.doi.org/10.1007/s00268-022-06501-4DOI Listing
June 2022

Comparison of extended totally extra peritoneal (eTEP) vs intra peritoneal onlay mesh (IPOM) repair for management of primary and incisional hernia in terms of early outcomes and cost effectiveness-a randomized controlled trial.

Surg Endosc 2022 Mar 11. Epub 2022 Mar 11.

Department of Surgical Disciplines, All India Institute of Medical Sciences, Room No. 5026A, 5th Floor, Teaching Block, Ansari Nagar, New Delhi, 110029, India.

Background: There are no randomized controlled trials comparing the eTEP with IPOM repair and this randomized study was designed to compare the two techniques in terms of early pain, cost effectiveness, and quality of life.

Method: This was a prospective randomized trial with intention to treat analysis. The primary outcome was immediate post-operative pain scores. Operative time, conversions, peri operative morbidity, hospital stay, return to daily activities, incremental cost effectiveness ratio and quality of life (WHO-QOL BREF) were secondary outcomes.

Results: Sixty patients were randomized equally. Early post-operative pain scores and seroma rates were significantly lower and with a significantly earlier return to activity in eTEP group (p value < 0.05). With negative costs and positive effects, eTEP group was 2.4 times more cost effective.

Conclusion: eTEP repair is better in terms of lesser early post-operative pain, earlier return to activities and cost effectiveness in small and medium size defects.
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http://dx.doi.org/10.1007/s00464-022-09180-3DOI Listing
March 2022

Timing of intraoperative crystalloid infusion may decrease total volume of infusate without affecting early graft function in live related renal transplant surgery: A randomized, surgeon-blinded clinical study.

Indian J Urol 2022 Jan-Mar;38(1):53-61. Epub 2022 Jan 1.

Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

Introduction: Early graft function is crucial for successful kidney transplantation. Intravascular volume maintenance is paramount in ensuring reperfusion of transplanted kidney. This study was planned to compare whether the timing of fluid infusion can help to decrease amount of fluid given without altering early graft function during renal transplantation.

Materials And Methods: The present study included forty recipients, randomized into standard (Group-S) or targeted fluid therapy (Group-T). Group S received fluid according to conventional fasting deficit while Group T received at 1 ml/kg/h from the start of surgery till start of vascular anastomosis after which fluid infusion rate in both group was increased to maintain a central venous pressure of 13-15 mm of Hg till reperfusion. Primary outcome measured was serum creatinine level on first postoperative day while secondary outcomes were IV fluid given, perioperative hemodynamics, onset of diuresis, graft turgidity, urine output, and renal function during first 6 postoperative days.

Results: The study showed Group T postoperatively had early fall in serum creatinine (day 3) than S (day 6) although this difference was not statistically significant. Group T had received significantly less fluid per kg of dry weight (T-42.7 ± 9.7 ml/kg, S-61.1 ± 11.1 ml/kg, < 0.001), had early diuresis, better graft turgidity and urine output than Group S.

Conclusion: Targeted hydration significantly decreases the total amount of fluid infused during the intraoperative period without altering early graft function. Targeted hydration during vascular anastomosis produced stable hemodynamics and early diuresis without any side-effects pertaining to hypo or hyper-volemia.Clinical trial identifier number-CTRI/2016/07/007111.
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http://dx.doi.org/10.4103/iju.iju_239_21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8796753PMC
January 2022

Peritoneal Loose Body in a Patient With Ampullary Adenocarcinoma.

ACG Case Rep J 2021 Nov 18;8(11):e00680. Epub 2021 Nov 18.

Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.14309/crj.0000000000000680DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8604031PMC
November 2021

Endoscopic transmural drainage tailored to quantity of necrotic debris versus laparoscopic transmural internal drainage for walled-off necrosis in acute pancreatitis: A randomized controlled trial.

Pancreatology 2021 Oct 21;21(7):1291-1298. Epub 2021 Jun 21.

Gastroenterology, All India Institute of Medical Sciences, New Delhi, India. Electronic address:

Background And Aims: Both endoscopic and laparoscopic transmural internal drainage are practiced for drainage of walled-off necrosis (WON) following acute pancreatitis (AP) but the superiority of either is not established. Our aim was to compare transperitoneal laparoscopic drainage with endoscopic drainage using either lumen apposing metal stents (LAMS) or plastic stents tailored to the amount of necrotic debris in WON.

Methods: In a randomized controlled trial, adequately powered to exclude the null hypothesis, patients with symptomatic WON were randomized to either endoscopic or laparoscopic drainage. In the endoscopy group, two plastic stents were placed if the WON contained <1/3rd necrotic debris and a LAMS was placed if it was >1/3rd. Primary outcome was resolution of WON within 4 weeks without re-intervention for secondary infection. Secondary outcome was overall success (resolution of WON at 6 months) and adverse events.

Results: Forty patients were randomized: 20 to each group. Baseline characteristics were comparable between the groups. Primary outcome was similar between the groups [16 (80%) in laparoscopy and 15 (75%) in endoscopy group; p = 0.89]. The overall success was similar [18 (90%) in laparoscopy vs. 17 (85%) in endoscopy; p = 0.9]. Median duration of hospital stay was shorter in endoscopy group [4 (4-8) vs. 6 days (5-9); p = 0.03]. Adverse events were comparable between the groups.

Conclusion: Laparoscopic drainage was not superior to endoscopic transmural drainage with placement of multiple plastic stent or LAMS depending on the amount of necrotic debris for symptomatic WON in AP. The hospital stay was shorter with the endoscopic approach.
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http://dx.doi.org/10.1016/j.pan.2021.06.006DOI Listing
October 2021

Impact of clinical parameters and vascular haemodynamics on arterio-venous fistula maturation in patients with end stage renal disease: A prospective study on Indian patients.

J Vasc Access 2021 Mar 14:11297298211001158. Epub 2021 Mar 14.

Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.

Background: About 18%-65% of Arterio-Venous fistula (AVF) made to facilitate haemodialysis in end stage renal disease patient fail to mature. This study was designed to evaluate the impact of clinical parameters and vascular haemodynamics on maturation of AVF on Indian patients.

Material And Methods: This was a prospective observational study. Eligible patients' clinical profiles and vascular haemodynamics by Doppler ultrasonography were noted. All patients underwent radio-cephalic AVF on the non-dominant arm under local anaesthesia. Clinical definition was used to assess success rate of AVFs which is defined as successful six settings of satisfactory dialysis. Data were analysed using Stata/12.0 software. Independent -test, chi-square test, logistic regression analysis and multivariate analysis were used. The -value of <0.05 was considered significant.

Results: A total of 205 patients were enrolled and analysed. Among clinical factors, age, sex, serum creatinine, hypertension had no significant association with failure (p = 0.5, 0.08, 0.76 and 0.74). Patient's BMI and presence of diabetes had significant impact on outcome ( < 0.001 and 0.02 respectively). Among vascular haemodynamics, radial vein diameter of >2.5 mm and radial artery flow rate >40 ml/min had no significant association with failure ( = 0.12 and 0.28). Diameter of radial artery (>2 mm) and intra-operatively immediate thrill were independent predictor of success (p = 0.002 and <0.001).

Conclusion: In the present study rate of fistula, maturation was 73.2% without any post-operative radiological intervention. Radial artery diameter >2 mm and presence of immediate thrill post-operatively were significantly associated with successful cannulation.
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http://dx.doi.org/10.1177/11297298211001158DOI Listing
March 2021

Diabetes mellitus in pheochromocytoma and paraganglioma: Prevalence, dynamics of insulin secretion / sensitivity and predictors of remission.

Diabetes Metab Syndr 2020 Nov-Dec;14(6):2169-2175. Epub 2020 Nov 5.

Department of Endocrinology and Metabolism, All India Institute of Medical Sciences(AIIMS), New Delhi, India.

Background And Aims: Pheochromocytoma and paraganglioma (PPGL) are associated with dysglycemia and diabetes mellitus (DM) much of which improves post operatively. In this study, we set out to ascertain pre and post-operative prevalence of DM in patients with PPGL based on oral glucose tolerance test (OGTT) and HbA1c and to evaluate effect of insulin secretion and sensitivity indices on DM pre-operatively.

Methods: Clinical and anthropometric data collection, HbA1c, 75 g OGTT with serum insulin estimation were done pre-operatively (n = 34) and at follow-up after successful surgery (n = 24) in patients with PPGL.

Results: Pre and post-operative prevalence of DM were 48%(18/37) and 17% (4/24) respectively. Comparison of patients with highest (Q4) and lowest (Q1) quartiles of insulinogenic index (IGI),a parameter of insulin secretion, revealed trends towards higher prevalence of DM in patients with lower IGI (Q4 to Q1: 29% versus 71%,n = 28, p = 0.24)but no association was observed with HOMA-IR (Q4 to Q1:50% versus 57%, n = 28, p = 1.00), an insulin sensitivity index. DM remitted in 77% patients post-operatively, predicted by duration of DM of<3 years.

Conclusion: There is high prevalence of DM in PPGL, with marked remission post-operatively, especially predicted by shorter duration of DM. Impaired insulin secretion is more strongly associated with pre-operative DM than increased insulin resistance.
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http://dx.doi.org/10.1016/j.dsx.2020.10.030DOI Listing
October 2021

Evaluation of the Graft Kidney in the Early Postoperative Period: Performance of Contrast-Enhanced Ultrasound and Additional Ultrasound Parameters.

J Ultrasound Med 2021 Sep 12;40(9):1771-1783. Epub 2020 Nov 12.

Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.

Objectives: To evaluate the various quantitative parameters of Doppler ultrasound, contrast-enhanced ultrasound (CEUS), and shear wave elastography (SWE) of graft kidneys in the early postoperative period and to explore their utility in the diagnosis of parenchymal causes of graft dysfunction.

Methods: In this ethically approved study, consecutive patients who underwent renal transplantation from March 2017 to August 2018 were recruited, and those with urologic or vascular complications and those who denied consent were excluded. All patients underwent ultrasound with Doppler, SWE, CEUS (using sulfur hexafluoride), and renal scintigraphic examinations 3 to 10 days after transplantation. A composite reference standard was used, including the clinical course, renal function test results, urine output, and histopathologic results for graft dysfunction. Cortical SWE values, quantitative CEUS parameters (generated from a time-intensity curve), and their ratios were analyzed to identify graft dysfunction and differentiate acute tubular necrosis (ATN) from acute rejection (AR).

Results: Of the 105 patients included, 19 developed graft dysfunction (18.1%; 12 ATN, 5 AR, and 2 drug toxicity) in the early postoperative period. The peak systolic velocity in the interpolar artery showed a significant difference between control and graft dysfunction groups (P < .001) as well as between ATN and AR (P = .019). Resistive indices and SWE did not show significant differences. Ratios of the time to peak showed a significant difference between control and graft dysfunction groups (P < .05). The rise time and fall time of the large subcapsular region of interest and the rise time ratio were significantly different between ATN and AR (P = .03).

Conclusions: Contrast-enhanced ultrasound can be used to diagnose parenchymal causes of early graft dysfunction with reasonable diagnostic accuracy.
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http://dx.doi.org/10.1002/jum.15557DOI Listing
September 2021

Effect of structured training in improving the ergonomic stress in laparoscopic surgery among general surgery residents.

Surg Endosc 2021 08 1;35(8):4825-4833. Epub 2020 Sep 1.

Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.

Background: Minimal access surgery has fast become the standard of care for many operative procedures, but is associated with lot of ergonomic stress to the surgeons performing these procedures, which may result in reduction in surgeon's performance and work capacity. In this study, we evaluated the impact of structured training program in improving the ergonomic stress in trainee laparoscopic surgeons.

Methods: Laparoscopic surgeons were divided in 2 groups: trainee surgeons (ten) and expert surgeons (three). Baseline surface electromyography (sEMG) data were collected from bilateral deltoid, biceps brachii, forearm extensors, and pronator teres during a predefined suturing task on Tuebingen trainer with integrated porcine organs in both the groups. Trainee surgeons underwent 20 h of laparoscopic intra-corporeal suturing training and surface electromyography data were recorded at the end of training again and compared with baseline.

Results: Experts were found to have lower muscle activation (p < 0.05) and muscle work (p < 0.05) and better bimanual dexterity than the trainee surgeons at baseline. After training, the trainee surgeons showed significant improvement (p = 0.01), but still did not reach the values of the expert surgeons (p = 0.01). Right deltoid and pronator teres muscles were found to have maximal activity while performing intra-corporeal suturing.

Conclusion: Structured and focused training outside operation theater can significantly reduce unnecessary muscle activation of trainee laparoscopic surgeons and better dexterity leading on to lesser ergonomic stress and thus possibly may reduce the risk of development of future musculo-skeletal disorders.
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http://dx.doi.org/10.1007/s00464-020-07945-2DOI Listing
August 2021

International expert consensus on laparoscopic pancreaticoduodenectomy.

Hepatobiliary Surg Nutr 2020 Aug;9(4):464-483

Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.

Importance: While laparoscopic pancreaticoduodenectomy (LPD) is being adopted with increasing enthusiasm worldwide, it is still challenging for both technical and anatomical reasons. Currently, there is no consensus on the technical standards for LPD.

Objective: The aim of this consensus statement is to guide the continued safe progression and adoption of LPD.

Evidence Review: An international panel of experts was selected based on their clinical and scientific expertise in laparoscopic and open pancreaticoduodenectomy. Statements were produced upon reviewing the literature and assessed by the members of the expert panel. The literature search and its critical appraisal were limited to articles published in English during the period from 1994 to 2019. The Web of Science, Medline, and Cochrane Library and Clinical Trials databases were searched, The search strategy included, but was not limited to, the terms 'laparoscopic', 'pancreaticoduodenectomy, 'pancreatoduodenectomy', 'Whipple's operation', and 'minimally invasive surgery'. Reference lists from the included articles were manually checked for any additional studies, which were included when appropriate. Delphi method was used to establish expert consensus and the AGREE II-GRS Instrument was applied to assess the methodological quality and externally validate the final statements. The statements were further discussed during a one-day face-to-face meeting at the 1 Summit on Minimally Invasive Pancreatico-Biliary Surgery in Wuhan, China.

Findings: Twenty-eight international experts from 8 countries constructed the expert panel. Sixteen statements were produced by the members of the expert panel. At least 80% of responders agreed with the majority (80%) of statements. Other than three randomized controlled trials published to date, most evidences were based on level 3 or 4 studies according to the AGREE II-GRS Instrument.

Conclusions And Relevance: The Wuhan international expert consensus meeting on LPD has produced a set of clinical practice statements for the safe development and progression of LPD. LPD is currently in its development and exploration stages, as defined by the international IDEAL framework for surgical innovation. More robust randomized controlled trial and registry study are essential to proceed with the assessment of LPD.
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http://dx.doi.org/10.21037/hbsn-20-446DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7423539PMC
August 2020

A prospective randomized comparison of sexual function and semen analysis following laparoscopic totally extraperitoneal (TEP) and transabdominal pre-peritoneal (TAPP) inguinal hernia repair.

Surg Endosc 2021 06 15;35(6):2936-2941. Epub 2020 Jun 15.

Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.

Background: With standardization of laparoscopic technique of groin hernia repair, the focus of surgical outcome has shifted to lesser studied parameters like sexual function and fertility.

Methods: This prospective randomized study was conducted in a single surgical unit at a tertiary care hospital. A sample size of 144 was calculated with 72 in each group (Group 1 TEP and Group 2 TAPP). Primary outcomes measured included comparison of sexual function using BMFSI, qualitative semen analysis and ASA levels between patients undergoing TEP or TAPP repair. Semen analysis and ASA was measured pre-operatively and 3 months post-operatively.

Results: A total of 145 patients were randomized into two groups, TAPP (73) and TEP (72) patients. Both the groups were comparable in terms of demographic profile and hernia characteristics with majority of the patients in both the groups having unilateral inguinal hernia (89.0% in TAPP group and 79.2% in TEP group). Both the groups showed statistically significant improvement in overall sexual function score (BMFSI) at 3 months; however, there was no inter group difference. Both the groups were also comparable in terms of ASA and qualitative semen analysis.

Conclusion: Both TEP and TAPP repair are comparable in terms of sexual function and effect on semen analysis. Laparoscopic repair improves the overall sexual functions in patients with groin hernia.
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http://dx.doi.org/10.1007/s00464-020-07733-yDOI Listing
June 2021

Surgical practice recommendations for minimal access surgeons during COVID 19 pandemic - Indian inter-society directives.

J Minim Access Surg 2020 Jul-Sep;16(3):195-200

Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.

These are inter-society guidelines for performance of laparoscopic surgery during COVID-19 pandemic that has affected the way of surgical practice. The safety of healthcare workers and patients is being challenged. It is prudent that our surgical practice should adapt to this rapidly changing health environment. The guidance issued is based on global practices and national governmental directives. The Inter-Society Group urges you to be updated with the developing situation and evolving changes.
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http://dx.doi.org/10.4103/jmas.JMAS_93_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7440016PMC
June 2020

Aggressive pelvic angiomyxoma and its mimics: can imaging be the guiding light?

Br J Radiol 2020 Jul 21;93(1111):20200255. Epub 2020 May 21.

Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.

Objective: To evaluate the imaging characteristics of aggressive angiomyxoma (AA) and identify features which would help to differentiate it from similar appearing lesions.

Methods: A retrospective review of departmental records was done and cases where AA was suspected on CT or MRI were included. With histopathology as gold-standard, the cases were grouped into AA or mimics and differentiating features were identified on USG, CT and MRI. Fischer's exact test was applied for the statistical significance of the differentiating features.

Results: 18 patients were identified of which 2 were excluded for lack of histopathology records. 10 were AA and 6 mimics which included 2 fibromatoses, 2 neurogenic tumors, and 1 each of germ cell tumor and inflammatory myofibroblastic tumor. On MRI, all AA showed T2 hyperintensity and intense contrast enhancement with characteristic laminated pattern in 7/9 cases. Diffusion restriction was seen in 2/3 cases, cystic component in 4/10 and hemorrhage in 1/10 cases. Pelvic fibromatosis was the closest imaging differential showing laminated pattern in one of the cases.

Conclusion: Large pelvic mass with abdominal/perineal extension in reproductive age female patient should lead to suspicion of AA. Laminated pattern on weighted images and intense homogeneous contrast enhancement further add to the diagnostic confidence.

Advances In Knowledge: This study for the first time describes radiological mimics of AA. Large cystic component, diffusion restriction, hemorrhage and organ infiltration have not been previously described in AA.
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http://dx.doi.org/10.1259/bjr.20200255DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7336078PMC
July 2020

Outcomes following laparoscopic internal drainage of walled off necrosis of pancreas: experience of 134 cases from a tertiary care centre.

Surg Endosc 2020 11 6;34(11):5117-5121. Epub 2019 Dec 6.

Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.

Introduction: Internal drainage of walled of necrosis of pancreas has been considered as the standard of care. For symptomatic walled off necrosis (WON) of pancreas with the advent of laparoscopy and refinement of techniques and instrumentation, laparoscopic internal drainage is becoming the standard surgical drainage procedure for these patients. However, there is a dearth of literature regarding outcomes following laparoscopic drainage. Most of the studies have small number of patients with limited follow-up. We in this study describe our experience of laparoscopic internal drainage of walled off necrosis over the last 13 years.

Materials And Methods: This is a retrospective analysis of a prospectively maintained database. All patients with WON undergoing laparoscopic internal drainage between January 2005 and December 2018 were included. Primary outcome measure was successful drainage. Secondary outcome measures included morbidity, hospital stay, re-intervention rate and mortality. Patients were followed up post-operatively at 1 week, 4 weeks, 3 months and then annually thereafter. Ultrasonography was done periodically for the assessment of cyst resolution.

Results: Between 2005 and 2018, 154 surgical drainage procedures were performed for symptomatic pseudocyst/walled off necrosis. Out of these, 134 underwent laparoscopic drainage; 129 patients (96.3%) underwent laparoscopic cystogastrostomy and 5 (3.7%) underwent laparoscopic cystojejunostomy. Majority of the patients were male (male:female = 6:1) with a mean age of 36 ± 12.9 years (range 15-58 years). The mean operative time was 94 min (range 64-144 min). There were three conversions because of intra-operative bleeding. The overall post-operative morbidity was 8.9%. The average hospital stay was 4.4 days (2-19 days). The mean duration of follow-up was 5.5 years (range 6 months-13 years). Complete cyst resolution was achieved in 95.5% (n = 128) patients. There has been no mortality till date.

Conclusion: In conclusion, laparoscopic internal drainage is a very effective technique for drainage of WON with an excellent success rate.
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http://dx.doi.org/10.1007/s00464-019-07282-zDOI Listing
November 2020

Unusual pseudocyst in a wandering spleen.

BMJ Case Rep 2019 Sep 5;12(9). Epub 2019 Sep 5.

General Surgery, All India Institute of Medical Sciences, New Delhi, Delhi, India.

Pseudocysts of the spleen are rare, generally asymptomatic lesions developing secondary to trauma, infection or infarction. When symptomatic, they typically present as non-specific pain in the left hypochondrium, with or without a palpable lump on clinical examination. However, these conventions fail when they occur in a wandering spleen, making imaging critically important. This report describes an unusual case of a 50-year-old who presented with a large cystic mass in a pelvic spleen; imaging facilitated a successful splenectomy and subsequent histopathology revealed a pseudocyst in a wandering spleen.
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http://dx.doi.org/10.1136/bcr-2019-229948DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6731936PMC
September 2019

Endoscopic versus laparoscopic drainage of pseudocyst and walled-off necrosis following acute pancreatitis: a randomized trial.

Surg Endosc 2020 03 28;34(3):1157-1166. Epub 2019 May 28.

Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.

Background: Pancreatic fluid collections (PFC) may develop following acute pancreatitis (AP). Endoscopic and laparoscopic internal drainage are accepted modalities for drainage of PFCs but have not been compared in a randomized trial. Our objective was to compare endoscopic and laparoscopic internal drainage of pseudocyst/walled-off necrosis following AP.

Patients And Methods: Patients with symptomatic pseudocysts or walled-off necrosis suitable for laparoscopic and endoscopic transmural internal drainage were randomized to either modality in a randomized controlled trial. Endoscopic drainage comprised of per-oral transluminal cystogastrostomy. Additionally, endoscopic lavage and necrosectomy were done following a step-up approach for infected collections. Surgical laparoscopic cystogastrostomy was done for drainage, lavage, and necrosectomy. Primary outcome was resolution of PFCs by the intended modality and secondary outcome was complications.

Results: Sixty patients were randomized, 30 each to laparoscopic and endoscopic drainage. Both groups were comparable for baseline characteristics. The initial success rate was 83.3% in the laparoscopic and 76.6% in the endoscopic group (p = 0.7) after the index intervention. The overall success rate of 93.3% (28/30) and 90% (27/30) in the laparoscopic and endoscopic groups respectively was also similar (p = 1.0). Two patients in the laparoscopic group required endoscopic cystogastrostomy for persistent collections. Similarly, two patients in the endoscopic group required laparoscopic drainage. Postoperative complications were comparable between the groups except for higher post-procedure infection in the endoscopic group (19 vs. 9; p = 0.01) requiring endoscopic re-intervention.

Conclusions: Endoscopic and laparoscopic techniques have similar efficacy for internal drainage of suitable pancreatic fluid collections with < 30% debris. The choice of procedure should depend on available expertise and patient preference.
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http://dx.doi.org/10.1007/s00464-019-06866-zDOI Listing
March 2020

An Analysis of Presentation, Pattern and Outcome of Chest Trauma Patients at an Urban Level 1 Trauma Center.

Indian J Surg 2018 Feb 19;80(1):36-41. Epub 2016 Oct 19.

1Department of Surgery, JPN Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, 110029 India.

Chest trauma is an important public health problem accounting for a substantial proportion of all trauma admissions and deaths. It directly account for 20-25 % of deaths due to trauma. Therefore, this study was conducted to analyze the presentation, patterns, and outcome of chest trauma in a level-1 urban trauma center. It was a prospective observational study of all patients presented with chest trauma to an urban level 1-trauma center over a period of 3 years. Demographic profile, mechanism of injury, injury severity scores (ISS), associated injuries, hospital stay, etc. were recorded. Morbidity and mortality rates were analyzed and compared with the published literature. Chest injuries comprised 30.9 % of all trauma admissions and the mechanism was blunt in majority (83.5 %) of the cases. Vehicular crashes (59.7 %) followed by assault were the most common modes of injury. Rib fracture was the most common chest injury seen in 724 of the 1258 patients while abdominal visceral injuries were the commonest associated injuries in polytrauma cases. Majority of the patients were managed non-operatively. Inter costal tube drainage (ICD) was the main stay of treatment in 75 % of the cases, whereas, thoracotomy was required only in 5.56 % of the patients. Overall mortality was 11 % and it was found to be significantly higher following blunt chest trauma. We observed that associated extra thoracic injuries resulted in higher mortality as compared to isolated chest injuries. Thoracic injuries can be readily diagnosed in the emergency department by meticulous and repeated clinical evaluation and majority require simple surgical procedures to prevent immediate mortality and long-term morbidity.
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http://dx.doi.org/10.1007/s12262-016-1554-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5866799PMC
February 2018

Is perioperative administration of 5% dextrose effective in reducing the incidence of PONV in laparoscopic cholecystectomy?: A randomized control trial.

J Clin Anesth 2017 Aug 12;40:7-10. Epub 2017 Apr 12.

Department of Surgery, All India Institute of Medical Sciences (AIIMS), New Delhi, India.

Study Objective: To compare the incidence of postoperative nausea and vomiting (PONV) during perioperative administration of 5% dextrose and normal saline in laparoscopic cholecystectomy.

Design: Prospective, randomized, double-blind trial.

Setting: Operating rooms in a tertiary care hospital of Northern India.

Patients: One hundred patients with American Society of Anesthesiologists status I to II undergoing laparoscopic cholecystectomy were enrolled in this study.

Interventions: Patients were randomized into two groups [normal saline (NS) group and 5% dextrose (D) group]. Both the groups received Ringer acetate (Sterofundin ISO) intravenously as a maintenance fluid during intraoperative period. Besides this, patients of group NS received 250ml of 0.9% normal saline and patients of group D received 5% dextrose @ 100ml/h started at the time when gall bladder was taken out. It was continued in the postoperative period with the same rate till it gets finished.

Measurements: Incidence of PONV, Apfel score, intraoperative opioids used and consumption of rescue antiemetics.

Main Results: Demographic data was statistically similar. Out of total 100 patients, 47 patients (47%) had PONV. In group D, 14 patients (28%) had PONV while in group NS, 33 patients (66%) had PONV within 24h of surgery (p value 0.001). The incidence of PONV was reduced by 38% in group D which is significantly lower when compared with that of group NS (p value 0.001). The consumption of single dose of rescue antiemetics in group D was also reduced by 26% when compared to that of group NS (p value 0.002).

Conclusions: Perioperative administration of 5% dextrose in patients undergoing laparoscopic surgery can reduce PONV significantly and even if PONV occurs, the quantity of rescue antiemetics to combat PONV is also reduced significantly.
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http://dx.doi.org/10.1016/j.jclinane.2017.03.048DOI Listing
August 2017

Role of Laparoscopy in Patients With Abdominal Trauma at Level-I Trauma Center.

Surg Laparosc Endosc Percutan Tech 2018 Feb;28(1):20-25

JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India.

Introduction: Abdominal trauma is one of the preventable causes of death in polytrauma patients. Decision and timing of laparotomy is a major challenge. Rate of nontherapeutic laparotomy is still high. Laparoscopy can avoid nontherapeutic laparotomy and also provide a reliable and accurate diagnosis of injury.

Materials And Methods: This ambispective observational study was conducted in the division of Trauma Surgery and Critical Care, JPN Apex Trauma Centre, All India Institute Medical Sciences, New Delhi. Retrospective analysis of prospectively maintained data of cases from January 1, 2008 through April 30, 2013 and prospective analysis of cases from May 1, 2013 through March 31, 2015 was done using appropriate measures. Hemodynamically stable or responders fulfilling inclusion criteria were included. Selected patients underwent the laparoscopic procedure and if required converted to laparotomy.

Results: Of the 3610 patients of abdominal trauma, laparotomy was done in 1666 (46.14%) patients and laparoscopy was done in 119 (3.29%) patients. Rate of reduction of nontherapeutic laparotomy in patients with abdominal trauma using diagnostic laparoscopy was 55.4%. However laparotomy could be avoided in 59.7%. Laparoscopy was 100% accurate in identifying injuries in our study. No injuries were missed in these patients. Fever and wound infection were significantly higher in laparotomy group. Chest infection and sepsis were also higher in laparotomy group but the difference was not statistically significant. Median length of hospital stay in laparoscopy group was 4 days (range: 1 to 28 d) and in laparotomy group was 9.5 days (range: 2 to 55 d) with P-value of 0.001.

Conclusions: Laparoscopy has a role in management of hemodynamically stable patients with suspected abdominal injury to prevent nontherapeutic laparotomies, and thereby decreasing postoperative complications.
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http://dx.doi.org/10.1097/SLE.0000000000000379DOI Listing
February 2018

Intraoperative on-table endoscopic retrograde cholangiopancreatography (ERCP) is better than laparoscopic bile duct exploration for concomitant bile duct stones during emergency laparoscopic cholecystectomy.

Evid Based Med 2017 03 11;22(1):27. Epub 2016 Nov 11.

Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, Delhi, India.

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http://dx.doi.org/10.1136/ebmed-2016-110549DOI Listing
March 2017

Outcomes of Laparoscopic Common Bile Duct Exploration After Failed Endoscopic Retrograde Cholangiopancreatography in Patients with Concomitant Gall Stones and Common Bile Duct Stones: A Prospective Study.

J Laparoendosc Adv Surg Tech A 2016 Dec 9;26(12):985-991. Epub 2016 Nov 9.

1 Department of Surgical Disciplines, All India Institute of Medical Sciences , New Delhi, India .

Introduction: The aim of the present study was to compare the outcomes of secondary laparoscopic CBD exploration (LCBDE) following failed endoscopic retrograde cholangiopancreatography (ERCP) and primary laparoscopic common bile duct (CBD) exploration.

Materials And Methods: One hundred eighty-five patients undergoing LCBDE were divided into Group I consisting of patients undergoing a primary LCBDE (n = 102) and Group II consisting of patients undergoing LCBDE after failure of ERCP to clear the CBD stones (n = 83). Primary outcome measure was successful laparoscopic CBD clearance. The secondary outcome measures were degree of difficulty, operative time, complications, hospital stay, and the cost of treatment.

Results: Success rate was similar in both groups (85.3% versus 80.7%). Mean operative time, degree of difficulty, hospital stay, and cost of procedure were significantly higher in Group II (P value <.05).

Conclusion: It may be prudent to consider ERCP failure patients for primary LCBDE than risk the complications of ERCP if they are suitable for primary surgery.
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http://dx.doi.org/10.1089/lap.2016.0272DOI Listing
December 2016

Analgesic efficacy of ultrasound guided transversus abdominis plane block versus local anesthetic infiltration in adult patients undergoing single incision laparoscopic cholecystectomy: A randomized controlled trial.

Anesth Essays Res 2016 Sep-Dec;10(3):561-567

Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

Background: Transversus abdominis plane (TAP) block has been used to provide intra- and post-operative analgesia with single incision laparoscopic (SIL) bariatric and gynecological surgery with mixed results. Its efficacy in providing analgesia for SIL cholecystectomy (SILC) via the same approach remains unexplored.

Aims: The primary objective of our study was to compare the efficacy of bilateral TAP block with local anesthetic infiltration for perioperative analgesia in patients undergoing SILC.

Settings And Design: This was a prospective, randomized, controlled, double-blinded trial performed in a tertiary care hospital.

Materials And Methods: Forty-two patients undergoing SILC were randomized to receive either ultrasound-guided (USG) bilateral mid-axillary TAP blocks with 0.375% ropivacaine or local anesthetic infiltration of the port site. The primary outcome measure was the requirement of morphine in the first 24 h postoperatively.

Statistical Analysis: The data were analyzed using -test, Mann-Whitney test or Chi-square test.

Results: The 24 h morphine requirement (mean ± standard deviation) was 34.57 ± 14.64 mg in TAP group and 32.76 ± 14.34 mg in local infiltration group ( = 0.688). The number of patients requiring intraoperative supplemental fentanyl in TAP group was 8 and in local infiltration group was 16 ( = 0.028). The visual analog scale scores at rest and on coughing were significantly higher in the local infiltration group in the immediate postoperative period ( = 0.034 and = 0.007, respectively).

Conclusion: USG bilateral TAP blocks were not effective in decreasing 24 h morphine requirement as compared to local anesthetic infiltration in patients undergoing SILC although it provided some analgesic benefit intraoperatively and in the initial 4 h postoperatively. Hence, the benefits of TAP blocks are not worth the effort and time spent for administering them for this surgery.
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http://dx.doi.org/10.4103/0259-1162.186620DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5062234PMC
October 2016

Is Interleukin 10 (IL10) Expression in Breast Cancer a Marker of Poor Prognosis?

Indian J Surg Oncol 2016 Sep 20;7(3):320-5. Epub 2016 Feb 20.

Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.

Interleukin 10 (IL10) is a poor prognostic marker in several cancers. Its role in breast cancer is not well elucidated. The present study is designed to see the expression of IL10 in breast cancer tissue and to evaluate its correlation with the established markers of prognosis. Sixty female patients who underwent surgery for breast cancer were enrolled for the study. Immediately after surgery, 2-5 g of tumour tissue and similar volume of peritumoural normal breast tissue were collected for IL10 assay. IL10 expression was assayed by immunohistochemistry. IL10 expressing tumours and IL10 non expressing tumours were compared. Chi square/Fisher exact test and student's t test were used to compare the data. p- valueless than 0.05 was considered as statistically significant. Thirty six patients (60 %) of carcinoma breast showed IL 10 expression in tumour tissue as compared to no IL 10 expression in any peritumouralnormal breast tissue (p < 0.01). IL10 expression had statistically significant correlation with locally advanced disease, tumour grade, HER2 + ve tumours and ER-ve, PR-ve, HER2 + ve breast cancer subtypes (p = 0.001, 0.001, 0.001 and 0.01 respectively). No correlation could be found with patient's age, tumour size, tumour histology and ER and PR status. Correlation of IL10 expressing tumours with several established poor prognostic markers of breast cancer may indicate the possible association of IL10 expression with poor prognosis. Large studies with long term follow up are needed to substantiate the association of IL10 with poor prognosis.
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http://dx.doi.org/10.1007/s13193-016-0512-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5016330PMC
September 2016

A prospective randomized comparison of testicular functions, sexual functions and quality of life following laparoscopic totally extra-peritoneal (TEP) and trans-abdominal pre-peritoneal (TAPP) inguinal hernia repairs.

Surg Endosc 2017 03 5;31(3):1478-1486. Epub 2016 Aug 5.

Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.

Background: There is very scant literature on the impact of inguinal hernia mesh repair on testicular functions and sexual functions following open and laparoscopic repair. The present randomized study compares TAPP and TEP repairs in terms of testicular functions, sexual functions, quality of life and chronic groin pain.

Methods: This study was conducted from April 2012 to October 2014. A total of 160 patients with uncomplicated groin hernia were randomized to either trans-abdominal pre-peritoneal (TAPP) repair or totally extra-peritoneal (TEP) repair. Testicular functions were assessed by measuring testicular volume, testicular hormone levels preoperatively and at 3 months postoperatively. Sexual functions were assessed using BMSFI, and quality of life was assessed using WHO-QOL BREF scale preoperatively and at 3 and 6 months postoperatively. Chronic groin pain was evaluated using the VAS scale at 3 months, 6 months and at 1 year.

Results: The median duration of follow-up was 13 months (range 6-18 months). The mean preoperative pain scores (p value 0.35) as well as the chronic groin pain were similar between TEP and TAPP repairs at 3 months (p value 0.06) and 6 months (p value 0.86). The testicular resistive index and testicular volume did not show any significant change at follow-up of 3 months (p value 0.9) in the study population. No significant difference was observed in testicular resistive index and testicular volume when comparing TEP and TAPP groups at at follow-up of 3 months (p value >0.05). There was a statistically significant improvement in the sexual drive score, erectile function and overall satisfaction over the follow-up period following laparoscopic inguinal hernia repair. However, sexual function improvement was similar in patients undergoing both TEP and TAPP repairs. All the domains of quality of life in the study population showed a significant improvement at a follow-up of 3 and 6 months. Subgroup analysis of all the domains of quality of life in both TAPP and TEP groups showed a similar increment as in the study population (p value <0.001); however, the mean scores of all the domains were comparable between the two subgroups (p value >0.05), preoperatively and 3 and 6 months follow-up.

Conclusions: Laparoscopic groin hernia repair improves the testicular functions, sexual functions and quality of life, but TEP and TAPP repairs are comparable in terms of these long-term outcomes.
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http://dx.doi.org/10.1007/s00464-016-5142-0DOI Listing
March 2017

Learning Curve in Laparoscopic Inguinal Hernia Repair: Experience at a Tertiary Care Centre.

Indian J Surg 2016 Jun 12;78(3):197-202. Epub 2015 Sep 12.

Department of Surgical Disciplines, All India Institute of Medical Sciences, Room No. 5021, 5th Floor Teaching Block, New Delhi, India.

One of the major reasons for laparoscopy not having gained popularity for repair of groin hernia is the perceived steep learning curve. This study was conducted to assess the learning curve and to predict the number of cases required for a surgeon to become proficient in laparoscopic groin hernia repair, by comparing two laparoscopic surgeons. The learning curve evaluation parameters included operative time, conversions, intraoperative complications and postoperative complications, and these were compared between the senior and the junior surgeon. One hundred thirty-eight cases were performed by the senior surgeon, and 63 cases by the junior surgeon. Both were comparable in terms of intraoperative and postoperative complications. Using the moving average method, minimum of 13 laparoscopic hernia repairs are required to reach at par the operating time of an experienced surgeon. For total extraperitoneal (TEP) repair, the number of cases was 14; and for transabdominal preperitoneal (TAPP) repair, this number was 13.
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http://dx.doi.org/10.1007/s12262-015-1341-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4907907PMC
June 2016

A prospective randomised controlled trial comparing chronic groin pain and quality of life in lightweight versus heavyweight polypropylene mesh in laparoscopic inguinal hernia repair.

J Minim Access Surg 2016 Apr-Jun;12(2):154-61

Department of Anaesthesiology, All India Institute of Medical Sciences, Delhi, India.

Background: The aim of our study was to compare chronic groin pain and quality of life (QOL) after laparoscopic lightweight (LW) and heavyweight (HW) mesh repair for groin hernia.

Materials And Methods: One hundred and forty adult patients with uncomplicated inguinal hernia were randomised into HW mesh group or LW mesh group. Return to activity, chronic groin pain and recurrence rates were assessed. Short form-36 v2 health survey was used for QOL analysis.

Results: One hundred and thirty-one completed follow-up of 3 months, 66 in HW mesh group and 65 in LW mesh group. Early post-operative convalescence was better in LW mesh group in terms of early return to walking (P = 0.01) and driving (P = 0.05). The incidence of early post-operative pain, chronic groin pain and QOL and recurrences were comparable.

Conclusion: Outcomes following laparoscopic inguinal hernia repair using HW and LW mesh are comparable in the short-term as well as long-term.
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http://dx.doi.org/10.4103/0972-9941.170018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4810950PMC
April 2016

Prospective Case-Control Study to Evaluate the Role of Glutathione S Transferases (GSTT1 and GSTM1) Gene Deletion in Breast Carcinoma and Its Prognostic Significance.

Indian J Surg 2015 Dec 5;77(Suppl 3):1067-72. Epub 2014 Aug 5.

Department of Anatomy, All India Institute of Medical Sciences, New Delhi, India.

Breast cancer is the most common cause of cancer death in women with the incidence rising in young women. GST gene polymorphisms are significant because of their role in the detoxification of both environmental carcinogens and also cytotoxic drugs used in therapy for breast cancer. The present study has been designed to identify the role of polymorphisms in GSTT1 and GSTM1 genes in the risk of development of breast cancer, in the prognostication of breast cancer, and in the prediction of response towards chemotherapy. Ninety-nine patients with breast cancer and 100 healthy controls with no history of cancer were taken from blood donors after informed consent. Epidemiological and clinical data was collected from participants and 5 ml of peripheral venous blood was collected for genotype analysis. Null genotype of GSTT1 was detected in 51.04 % of the controls in comparison to 20.2 % of patients with carcinoma breast, which was found to be statistically significant (OR 4.18; 95 % CI 2.01-8.75; P = 0.0001). GSTM1 gene deletion was also significantly more common among controls (60 %) than in patients with breast cancer (33 %) (OR 4.57; 95 % CI 2.20-9.51; P = 0.0001). Tumors more than 5 cm in size had greater tendency for GSTM1 gene expression (P value = 0.019), but other clinicopathological parameters did not show any correlation. GSTT1 and GSTM1 genes status did not show any association with response to chemotherapy. The results indicated the null genotype of both GSTT1 and GSTM1 to be protective for the development of carcinoma breast. None of the known etiological factors have any correlation with GSTT1 and GSTM1 gene deletion. Patients with small tumor size expressed GSTM1 gene deletion. Other tumor characteristics and clinicopathological parameters did not have any correlation with gene deletion.
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http://dx.doi.org/10.1007/s12262-014-1152-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4775586PMC
December 2015

Preventing Delayed Gastric Emptying After Whipple's Procedure-Isolated Roux Loop Reconstruction With Pancreaticogastrostomy.

Indian J Surg 2015 Dec 12;77(Suppl 2):703-7. Epub 2013 Nov 12.

Department of Surgical Disciplines, All India Institute of Medical Sciences, Room No. 5021, 5th Floor Teaching Block, New Delhi, India.

Although delayed gastric emptying (DGE) after Whipple's pancreaticoduodenectomy is not life-threatening and can be treated conservatively, it results in discomfort and significant prolongation of the hospital stay and adds on to the hospital costs. To overcome this problem, we started using the isolated loop technique of reconstruction along with pancreaticogastrostomy and we present our series using this technique. All consecutive patients undergoing Whipple's pancreaticoduodenectomy in a single surgical unit from January 2009 until December 2012 were included. In the absence of hepatic and peritoneal metastasis, resection (Whipple's procedure) with curative intent was done using isolated loop technique with pancreaticogastrostomy. Delayed gastric emptying was assessed clinically and on oral gastrograffin study. Bile reflux was also assessed on clinical parameters and evidence of beefy friable gastric mucosa on upper GI endoscopy and presence of reflux on hepatobiliary scintigraphy. A total of 52 patients were operated using this technique from January 2009 to October 2012. The mean operative time was 260.8 ± 50.3, and the mean operative blood loss was 1,068.0 ± 606.1 ml. Mean gastric emptying time 106.0 ± 6.1 min (89-258 min). Three out of the 52(5.7 %) patients had persistent vomiting in the post-operative period requiring reinsertion of NG tube. A HIDA scan done on POD7 for all patients did not show any evidence of bile reflux in any of the patients. Pancreatogastrostomy with isolated loop in pancreaticoduodenal resection markedly reduces the post-operative incidence of alkaline reflux gastritis and DGE.
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http://dx.doi.org/10.1007/s12262-013-0992-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4692950PMC
December 2015

Accuracy of Focused Assessment with Sonography for Trauma (FAST) in Blunt Trauma Abdomen-A Prospective Study.

Indian J Surg 2015 Dec 31;77(Suppl 2):393-7. Epub 2013 Jan 31.

Department of Forensic Medicine, All India Institute of Medical Sciences, New Delhi, India.

Focused assessment with sonography for trauma (FAST) is a limited ultrasound examination, primarily aimed at the identification of the presence of free intraperitoneal or pericardial fluid. In the context of blunt trauma abdomen (BTA), free fluid is usually due to hemorrhage, bowel contents, or both; contributes towards the timely diagnosis of potentially life-threatening hemorrhage; and is a decision-making tool to help determine the need for further evaluation or operative intervention. Fifty patients with blunt trauma abdomen were evaluated prospectively with FAST. The findings of FAST were compared with contrast-enhanced computed tomography (CECT), laparotomy, and autopsy. Any free fluid in the abdomen was presumed to be hemoperitoneum. Sonographic findings of intra-abdominal free fluid were confirmed by CECT, laparotomy, or autopsy wherever indicated. In comparing with CECT scan, FAST had a sensitivity, specificity, and accuracy of 77.27, 100, and 79.16 %, respectively, in the detection of free fluid. When compared with surgical findings, it had a sensitivity, specificity, and accuracy of 94.44, 50, and 90 %, respectively. The sensitivity of FAST was 75 % in determining free fluid in patients who died when compared with autopsy findings. Overall sensitivity, specificity, and accuracy of FAST were 80.43, 75 and 80 %, respectively, for the detection of free fluid in the abdomen. From this study, we can safely conclude that FAST is a rapid, reliable, and feasible investigation in patients with BTA, and it can be performed easily, safely, and quickly in the emergency room with a reasonable sensitivity, specificity, and accuracy. It helps in the initial triage of patients for assessing the need for urgent surgery.
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http://dx.doi.org/10.1007/s12262-013-0851-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4692944PMC
December 2015

Sequential occurrence of preneoplastic lesions and accumulation of loss of heterozygosity in patients with gallbladder stones suggest causal association with gallbladder cancer.

Ann Surg 2014 Dec;260(6):1073-80

*Departments of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India †Indian Agricultural Research Institute, New Delhi, India; Departments of ‡Pathology §Surgery ¶Pediatrics (Genetics unit), and ‖Biostatistics, All India Institute of Medical Sciences, New Delhi, India.

Background: Causal association of gallbladder stones with gallbladder cancer (GBC) is not yet well established.

Objective: To study the frequency of occurrence of preneoplastic histological lesions and loss of heterozygosity (LOH) of tumor suppressor genes in patients with gallstones.

Methods: All consecutive patients with gallstones undergoing cholecystectomy from 2007-2011 were included prospectively. Histological examination of the gallbladder specimens was done for preneoplastic lesions. LOH at 8 loci, that is 3p12, 3p14.2, 5q21, 9p21, 9q, 13q, 17p13, and 18q for tumor suppressor genes (DUTT1, FHIT, APC, p16, FCMD, RB1, p53, and DCC genes) that are associated with GBC was tested from microdissected preneoplastic lesions using microsatellite markers. These LOH were also tested in 30 GBC specimens.

Results: Of the 350 gallbladder specimens from gallstone patients, hyperplasia was found in 32%, metaplasia in 47.8%, dysplasia in 15.7%, and carcinoma in situ in 0.6%. Hyperplasia, metaplasia, and dysplasia alone were found in 11.7%, 24.6%, and 1.4% of patients, respectively. A combination of hyperplasia and dysplasia, metaplasia and dysplasia, and hyperplasia, metaplasia, and dysplasia was found in 3.4%, 6.3%, and 4.3% of patients, respectively. LOH was present in 2.1% to 47.8% of all the preneoplastic lesions at different loci. Fractional allelic loss was significantly higher in those with dysplasia compared with other preneoplastic lesions (0.31 vs 0.22; P = 0.042). No preneoplastic lesion or LOH was found in normal gallbladders.

Conclusions: Patients with gallstones had a high frequency of preneoplastic lesions and accumulation of LOH at various tumor suppressor genes, suggesting a possible causal association of gallstones with GBC.
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http://dx.doi.org/10.1097/SLA.0000000000000495DOI Listing
December 2014
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